Business planning in the NHS

Business planning in the NHS NHS trusts (England and Wales)‏ Health and Social Services Trusts (Northern Ireland)‏ Operating Divisions of NHS boards (Scotland)‏ • Required to prepare annual plans (also called service plans)‏ • Describes the NHS organisation’s long and short-term plans • Prepared on an annual basis and usually covers the three years ahead A business plan includes: • Statement on what the organisation intends to achieve • Assessment of the level of activity • Includes assessment of the ability of commissioners to support this • Plans for capital development • Plans for funding for developments • Analysis to take into account different assumptions or unexpected developments • Risk assessment

Why develop business plans? • Allows NHS organisations to integrate service developments within the financial planning year • Ensures services are well planned • Ensures services are financially viable • Ensures other consequences have been taken into account • eg staffing, maintenance etc

What is a business case? A document that supports the proposal for: • new service development • new equipment • due to increased workload • out dated equipment • new facilities • to comply with CPA • new/additional staff • increased workload • new service development • IT upgrades

What is a business case? Ideas for service development may come from • Clinicians requesting a new test to be introduced • Local research interest • Demand • National guidelines • UK National Screening Committee • Newborn screening for CF • NICE guidelines • Familial hypercholesterolaemia screening for patients with high cholesterol levels

Developing a business case • Initially - discussion with clinical director and directorate manager to assess feasibility of case and likelihood of success • Then, establish team to develop business case. Likely to be senior clinical and scientific staff, directorate manager, directorate accountant, possibly nurse specialists, staff from estates and supplies.

Developing a business case Step 1: Strategic context • Describe the current situation/service • Consider local and national policies that might impact on the provision of the new service • Undertake a SWOT analysis of the new service • Identify the need for change based on the differences between the existing service and the proposed new service • It is important that the proposed business case fits in with the annual plan of the relevant NHS Trust or organisation and also with national guidelines, for example, turnaround times.

Developing a business case SWOT analysis • Internal strengths, weaknesses are assessed against external opportunities and threats. • SWOT analysis is summarised in a TOWS matrix (2 x 2 chart) in which there is analysis of strengths versus opportunities, strengths versus threats, weaknesses versus opportunities and weaknesses versus threats. • This analysis identifies the need for change based on the differences between the existing service and future needs.

Developing a business case Step 2: Define the aims and objectives • Objectives should be SMART (specific, measurable, achievable, relevant, timed)‏ • Used to compare with baseline – ie existing service • Should be detailed enough for service aims to be clear but not too specific so that a range of options can’t be considered Identify benefit criteria • Benefits that are measured in non-financial terms • eg clinical quality • Improved patient outcomes • Benefits that are measured in financial terms • Benefits that are not easily measured • eg reduction in pressure on staff

Developing a business case Step 3: Develop an option appraisal • Identify a wide range of possible options available to meet objectives defined in Step 2. Option 1: Do nothing • This is essential as it clarifies the problems with the existing service identified in Step 1. Option 2: other plans Option 3: other plans • Each option should be described in detail so that benefits and costs can be assessed in Step 4.

Developing a business case Step 4: Assess each option for benefits and costs Measure benefits and costs of each option in Step 3 using benefit criteria identified in Step 2. • Establish team (business manager, accountant, service users) who will rank the options in order of preference. Might want independent advisor to ensure that there is no bias towards a particular option Weight the benefit criteria • Most important criterion given weight of 100 • If next criterion half as important as first then given weight of 50 • Other criteria weighted in the same way • Scaled to total of 100 Score the options against the benefit criteria • Each option considered against the benefit criteria and given a score 0 to 100

Developing a business case Step 4: Assess each option for benefits and costs • Multiply weighted benefit criteria by this score • Options can then be ranked in terms of benefits only Identify and measure costs • Aim – to identify the total net costs of each option • Estimate of: • Capital costs • Revenue costs • Costs related to changes in working practices eg training • Need to be as accurate as possible – involve financial manager • Overestimate may result in case being considered not financially viable • Underestimate will cause problems later and ruin credibility of project

Developing a business case • Step 5: Identify the preferred option (proposal)‏ • Analyse information generated in preceding steps • Best option might be one with maximum benefits and lowest costs • Identify any risks associated with preferred option and how these will be managed

Developing a business case Step 6: Present business case as a written report • Introduction • Aim • Option Appraisal • Proposal • Assessment of the impact of the proposal • Risk analysis • Conclusions and recommendations • Business case submitted to relevant directorate and considered against other cases. • Assessed by executive team • Agree to proceed • Agree in principle but request further work and re-submission • Turn down completely • Not necessarily funded in the same year

Commissioning and setting up a new service Factors to be taken into consideration • Is there clinical need for the test? • What is the prevalence of the disorder? • How many samples are expected? • Is there clinical demand for the test? • Where will referrals come from – local or external? • Is anyone requesting the new service? • Is testing available elsewhere, either in accredited lab or research basis? • Is there need for another lab to provide service?

Commissioning and setting up a new service • Does the new test have clinical utility? • Will the genetic test result in improved patient treatment/outcome? • Will the genetic test lead to testing/treatment for other family members? • Is the genetic test useful? • Consider incomplete penetrance, environmental factors. • Does the new test have clinical validity? • High sensitivity and specificity? • What is the potential workload for the laboratory? • Gene screen or targeted tests? • How long will it take to set up new service? • Will new funding be required?

Commissioning and setting up a new service • Is new equipment required? • Lease or buy? • If existing equipment used will it affect existing users/services of that equipment? • Period of training and validation • Training for new equipment • Training for new technology • Validation with known controls • Can the new test be carried out within approved TATs?

Example - Regional Familial Hypercholesterolaemia Service in North East England A real business case (2008)‏ Strategic context • NICE clinical guidelines (August 2008)‏ • “Identification and management of familial hypercholesterolaemia” • Prevalence of FH is 1 in 500 • Most cases caused by mutations in LDL-R gene • Leads to early development of atherosclerosis and coronary heart disease • 50% chance of CHD by age 60 in men, 50yrs in women • Population of North East is 3 million • Cardiovascular disease is the leading cause of premature death in the North East • Estimated to be 6000 affected people • Genetics service already participating in a cascade testing programme with the local lipid clinic

Example - Regional Familial Hypercholesterolaemia Service in North East England • Genetic testing of relatives with FH will enable early identification leading to treatment through diet, lifestyle interventions and cholesterol lowering drugs (statins). • FH screening service will provide equity of service provision.

Example - Regional Familial Hypercholesterolaemia Service in North East England Aims and objectives • Proposed service will be multi-disciplinary • Primary care and cardiology services will refer patients to the lipid clinic for confirmation of diagnosis of FH • Blood samples sent to Northern Regional Genetics Service for mutation analysis • If mutation is identified, cascade testing carried out on family members • Affected family members will be referred to lipid clinic for cholesterol management • Ongoing care provided by primary care • If mutation not identified cascade testing of family members using cholesterol levels carried out

Example - Regional Familial Hypercholesterolaemia Service in North East England Constraints • Educational resources required to inform primary care and cardiology services how to access FH service and explanation of referral criteria • Establishment of network of lipid clinics required to facilitate access to genetic testing and referral of affected family members identified through cascade testing • Problem exacerbated in the North East due to fatty diet and high prevalence of smoking Benefits • Prevention is better than cure or treatment • Cascade testing will enable early diagnosis and early treatment • FH service will reduce cost of patient care (surgery or long term care following CVD event)‏

Example - Regional Familial Hypercholesterolaemia Service in North East England Options • Option 1: Do nothing • Option 2: Lipid clinic led service • Option 3: Genetics led complete service • Option 4: Genetics led service no laboratory input Costs Set up costs • Laboratory equipment • Resources for educating primary care • Resources to establish lipid clinic networks Recurrent costs • Laboratory annual costs, consumables and staff • Half day of GP with special interest • Two genetic counsellors

Example - Regional Familial Hypercholesterolaemia Service in North East England Sensitivity to risk • If FH service not developed, the NICE guidelines will not be supported in the North East and care of patients will not be in line with the regional public health strategy The preferred option Option 3: Genetics led complete option

Co-ordinated national strategies • UKGTN • NCG • GenCAG • UK National Screening programmes • NICE

Co-ordinated national strategies UKGTN • UK Genetic Testing Network See Sian’s January presentation.... NCG • National Commissioning Group • Roleto commission services on a national basis for the population of England • Established in April 2007 • Formerly known as NSCAG – National Specialist Commissioning Advisory Group based at the Department of Health • now hosted at NHS London on behalf of all 10 SHAs • Two elements: • expert group whose role it is to advise Ministers on which services should be nationally commissioned • National Specialised Commissioning Team who support the NCG and implement its recommendations

Co-ordinated national strategies GenCAG Genetics Commissioning Advisory Group • Set up to take a strategic national overview of genetics in healthcare delivery • Aims to provide advice to commissioners of genetics services to enable them to provide appropriate services for NHS patients and their families • Provides advice to NCG • Advises on strategic development of genetics in healthcare delivery • Oversees UKGTN steering group • Anticipates and assesses the impact of new developments on service delivery • Works in liaison with: • R&D • HTA • the Knowledge Parks • NGRL labs

Co-ordinated national strategies GenCAG • Takes a patient centred view of requirements for Genetics services delivery • Works closely with the National Screening Committee where programmes have a genetic component • Liaises with the Human Genetics Commission in relation to developments with potential social and ethical implications • Members are drawn from: • relevant professional bodies and groups • the Royal Colleges • the Genetic Interest Group – GIG • specialised commissioning groups which commission these services in the NHS

Co-ordinated national strategies UK National Screening Programmes • See Simon’s December presentation.... NICE • National Institute for Health and Clinical Excellence • “Independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health” • Provides guidance in three areas: • public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector • health technologies - guidance on the use of new and existing medicines, treatments and procedures within the NHS • clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

Steps involved in developing NICE clinical guidelines: • Guideline topic is referred by Department of Health • Stakeholders register interest (national organisations representing patients and carers)‏ • Scope prepared. • National Collaborating Centre – (NCC) commissioned to develop the guideline and prepare the scope • Guideline development group established • made up of health professionals, representatives of patient and carer groups and technical experts • Draft guideline produced • Consultation on the draft guideline • Final guideline produced • Guidance issued to NHS

Business planning in the NHS